SHOT Annual Report 2009 - Serious Hazards of Transfusion

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are increasingly stressed by being spread thinly over many patients without proper information about the clinical progress and plans for those patients. Sick leave among junior doctors has increased hugely since implementation of the EWTD, and job satisfaction has reduced. 17 Unfortunately, the detrimental effect of these changes will take time to show in outcome figures for Trusts or types of patients – and action must be taken without waiting for these data. A new initiative by the Royal Colleges, spearheaded by the Royal College of Physicians, has developed a set of crossdisciplinary national standards and templates with e-learning modules in order to facilitate local implementation of a patient handover system. This tool allows a rolling electronic or paper update of current care, planned treatment and problems of patients, which is then used as the basis for a formal handover session at times of changing shift or on-call team. Handover templates are freely available and can be found at: http://www.rcplondon.ac.uk/clinical-standards/hiu/ medical-records/Pages/templates.aspx. Recommendation Trusts must implement the use of a documented handover tool, such as the one recently developed by the Royal Colleges, as part of a formal patient handover system. Action: DH, Trust CEOs Past recommendations still relevant Year first made Recommendation Target Progress 2008 See update on page 13. 2007 Transfusion Medicine must be part of the core curriculum for doctors in training. NBTC, GMC, PMETB, Royal Colleges, Deaneries The Royal Colleges and the Specialist Societies sub-group of the NBTC is addressing this. 2007 Professional, accredited staff must take responsibility for transfusion safety in the laboratory and in clinical practice. NBTC, UKTLC, BBTS, IBMS, Trust/hospital CEOs The UKTLC has published minimum standards for hospital transfusion laboratories. 10,11 2007 Obstetricians and midwives must be familiar with the anti-D prophylaxis programme and its rationale. NBTC, BCSH, RCM, RCOG, RCGP, HTTs and HTCs Educational days have taken place and been well attended. There appears to be a knowledge gap and educational programmes must continue to address this. 2007 Participation in haemovigilance must be improved as it is mandatory in the UK and the rest of Europe. DH, MHRA, SHOT, CEOs, HTCs, BTS Reporting to SHOT increased by 85% between 2007 and 2008, and a further 23% in 2008–2009. 2006 Speciality accredited laboratory and clinical staff in all hospitals. Hospital CEOs, NTLC, BBT network, RCN, BBTS The UKTLC has delivered recommendations to the DH. 2006 Comprehensive reporting to SHOT by all hospitals. Trust/hospital CEOs, SHOT, consultants with responsibility for transfusion, HTT, HTC SHOT reporting has definitely increased in 2008 and 2009, with increased reports, more participating organisations and more reports sent per organisation. 24 6. Key Messages and Main Recommendations
2005 Appropriate use of blood components. Consultant haematologists with responsibility for transfusion, HTTs, HTCs Overall reduction in red cell usage > 15% in last 5 years nationwide. National Comparative Audit (NCA) platelet audit showed widespread inappropriate use of platelets and non-adherence to guidelines (www.nhsbtaudits.co.uk). 2004 The RTC structure provides a potential forum for debate and sharing of problems and solutions in a supportive environment with expert clinical input. SHOT reportable incidents should be a standing agenda item for regional BMS forums and TP meetings. The RTCs should support translation of guidelines into local practice. RTCs and user groups NBS Hospital Liaison Teams focused support on RTCs in 2005. RTCs set up working groups in 2006. Realignment of RTCs with SHA regions in 2007. 2002 HTTs must be established and supported. Trust CEOs Survey in 2004 (Murphy & Howell) showed 70% of Trusts had HTT but only 30% were supported. A further survey in 2006 (Murphy & Howell) stated that 97% of Trusts had an HTC and 96% a TP. 2002 Blood transfusion should be in the curriculum of specialist trainees, especially anaesthetists and critical care nurses. Medical Royal Colleges, Universities The Royal Colleges and the Specialist Societies subgroup of the NBTC was established in 2007. 2002 Blood transfusion must be in the curriculum for student nurses, medical undergraduates and newly qualified doctors. GMC, PMETB, Undergraduate Deans, NMC An education subgroup of the NBTC has been established in 2007. SNBTS training package www.learnbloodtransfusion.org.uk endorsed in Scotland, Wales and NI. 2002 SHOT recommendations must be on the clinical governance agenda. Trust CEOs, Trust Risk Management Committees and HTCs No mechanisms for monitoring. 2001 An ongoing programme of education and training for all staff involved in transfusion. NBTCs and network, Trust CEOs, NPSA/ NBTC/SHOT initiative Mandated by NPSA SPN 14 ‘Right Patient, Right Blood’. Also a requirement of NHSLA standards. Educational tool www.learnbloodtransfusion.org.uk developed by SNBTS. 2001 Appropriate use of blood components must be strenuously promoted and evaluated. This must include monitoring for serious adverse effects of alternatives to transfusion. NBTC, Trust CEOs Successive BBT initiatives promote this. The NHSBT Appropriate Use Group and Patients’ Clinical Team are active. Red cell usage has fallen by > 15% since 2000. 2001 Transfusion practitioners should be appointed in all Trusts. Trust CEOs Requirement of BBT2. By 2005 appointed in 75% of hospitals (NCA organisational audit 2005). 2001 More transfusion medical consultant time is needed in hospital Trusts. Requirement of BBT2, but there is a national shortage of consultant haematologists. 1999 All institutions where blood is transfused must actively participate in SHOT. Trust CEOs Requirement of BBT and NHSLA. Reporting has improved in 2008 and 2009 (see above). 1997 There is a need for a national body with relevant expertise and resource to advise government on priorities for improvements in transfusion safety. DH MSBTO reviewed by DH. New committee SaBTO commenced meetings in 2008. 6. Key Messages and Main Recommendations 25
Page 1 and 2: Annual Report 2009 Affiliated to th
Page 3 and 4: Requests for further information sh
Page 5 and 6: 1. Foreword The Serious Hazards of
Page 7 and 8: 2. SHOT - The UK Haemovigilance Sch
Page 9 and 10: 3. Participation in Haemovigilance
Page 11 and 12: Figure 2 Number of reports sent per
Page 13 and 14: For the first time this year, SHOT
Page 15 and 16: 4. SHOT 2009-2010 UK Transfusion La
Page 17 and 18: Update on 2008 recommendations Last
Page 19 and 20: Numbers of components issued In 200
Page 21 and 22: Table 10 Cumulative mortality/morbi
Page 23 and 24: Acute transfusion reaction (ATR) Th
Page 25 and 26: 6. Key Messages and Main Recommenda
Page 27: Recommendation All pulmonary compli
Page 31 and 32: 7. Incorrect Blood Component Transf
Page 33 and 34: Table 12 Summary of IBCT cases Type
Page 35 and 36: Major morbidity There were 2 cases
Page 37 and 38: Wrong blood components transfused t
Page 39 and 40: Learning points ■■ All componen
Page 41 and 42: Table 15 Number of staff involved i
Page 43 and 44: All of the errors in this group wer
Page 45 and 46: Trust and sometimes in separate Tru
Page 47 and 48: IBCT events originating in the hosp
Page 49 and 50: multiple group O components; 1 grou
Page 51 and 52: Learning points ■■ ■■ Where
Page 53 and 54: Three interpretation errors occurre
Page 55 and 56: IT must be used to its full potenti
Page 57 and 58: Case 8 When the laboratory knows of
Page 59 and 60: ■■ All staff must take full pro
Page 61 and 62: 7.1 Errors Relating to IT Systems (
Page 63 and 64: to laboratory B. The clinical reque
Page 65 and 66: Improving Laboratory Standards (bas
Page 67 and 68: 7.2 Right Blood Right Patient (RBRP
Page 69 and 70: COMMENTARY Each year SHOT emphasise
Page 71 and 72: Core hours vs. out of hours and Whe
Page 73 and 74: Broad breakdown of where primary er
Page 75 and 76: Case 6 Dilute (possible drip arm) s
Page 77 and 78: Case 10 Over-transfusion following
Page 79 and 80:
9. Handling and Storage Errors (HSE
Page 81 and 82:
Excessive time to complete administ
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etween removing the component from
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10. Adverse Events Relating to Anti
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Omission or late administration of
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Anti-D Ig given to the wrong patien
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RECOMMENDATIONS New recommendations
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Case 1 Possible fatal reaction A ma
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adequate resources both for monitor
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Figure 12 Reaction by component typ
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Bacterial culture of patient and un
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Previous recommendations that are s
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Figure 13 Number of cases of HTR re
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Antibody only detectable in eluate
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Table 39 Serology, laboratory signs
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Table 40 DHTRs - New specificities
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13. Transfusion-Related Acute Lung
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Classification of cases according t
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Comparative data on implicated comp
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Case Histories TRALI probable Case
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RECOMMENDATIONS New recommendations
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Table 42 Cases classified according
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Clinical details and transfused flu
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Cases in which RBC transfusion was
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exchange in patients with TTP. 43 I
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15. Transfusion-Associated Dyspnoea
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16. Post-Transfusion Purpura (PTP)
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■■ The requirement to irradiate
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Two incidents (both bacterial, desc
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Viral and parasitic TTIs Since 1996
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The most likely source of the organ
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19. Autologous Transfusion Definiti
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RECOMMENDATIONS There are no new re
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Introduction and overall trends In
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incident group O D negative units w
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Table 47 Types of reactions for eac
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always require notification by clin
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21. Near Miss Reporting Definition
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29 UK Resuscitation Council Emergen
Page 157:
24. Acknowledgements The Steering G
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SHOT Annual Report 2009 - Serious Hazards of Transfusion

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